Analysis of direct ophthalmoscopy teaching in Medical graduation courses of Mato Grosso State

Objective: direct ophthalmoscopy teaching is receiving less attention during graduation, which results in doctors without confidence to perform the exam. Therefore, the self-perception of students from medical schools of Mato Grosso about the direct ophthalmoscopy and the main factors responsible for the insecurity on performing it was analyzed. Methods: a literature review was done using the databases Pubmed, Scielo and Biblioteca Virtual em Saúde, then a questionnaire was applied, through the snowball method and after favorable assent of the Ethics Committee, to medical students from Mato Grosso who were regularly enrolled in the fifth or sixth year of the course. Statistical analysis was performed on the SPSS 20 software, considering a confidence interval of 95%. Results: it was verified that the proportion of students that have had classes about direct ophthalmoscopy was superior in public schools (p < 0,001); that the majority of students does not believe that their schools provide adequate conditions for learning the exam (p = 0,001); that 10,5% considerate themselves knowledgeable about theory and practice regarding direct ophthalmoscopy (p = 0,004); that few training during graduation is the main factor that hinders learning the exam; and that this results in underconfidence at performing it. Conclusion: direct ophthalmoscopy is not receiving the deserved importance during medical graduation in the state of Mato Grosso. With these results, measures can be taken to improve the teaching-learning process of the technique, which can bring benefit to the population. university ensures proper learning of direct ophthalmoscopy.


IntRoductIon
D irect ophthalmoscopy (DO) is an important technique of medical propaedeutics (1) whereby the eye fundus is observed through the pupillary opening. The examination is carried out using a device called an ophthalmoscope, which allows illumination of the eye fundus and its evaluation by the examiner. With this technique it is possible to evaluate the red reflex, retina, optic disc and retinal vessels. (2) The workload devoted to the teaching of Ophthalmology during graduation has been increasingly reduced, (3) a matter of concern when considering that various extraocular diseases affect the eyes. These diseases include rheumatological, cardiac, endocrine, hematological, renal, dermatological and neurological diseases. These and other entities manifest important signs and symptoms in the eyes that guide the diagnosis, and thus establish early treatment and ensure a better prognosis. Especially in neurology, DO allows direct visualization and evaluation of a part of the central nervous system and its blood vessels. (4) For the general practitioner, the part of the most accessible basic ophthalmic propedeutics from a financial and diagnostic effectiveness point of view is DO. As it is considered a complex exam and its effective performance requires a lot of practice, it usually has little focus and makes many doctors and medical students feel insecure when carrying out the exam, leaving them dependent on an ophthalmologist or neurologist, which are not always available at the service location. (5) Epidemiological data show an important prevalence of retinal alterations mainly due to diabetes mellitus (DM) and systemic arterial hypertension (SAH) called retinopathy. (6) It is the role of the physician who works in primary health care to minimize the long-term complications of these diseases, (6) and in the case of ocular complications the main measure to enables that is OD, as it allows direct visualization of the affected region.
Given the clinical importance of DO, there is a need to improve its teaching during medicine graduation, (3) so that future doctors can more fully meet their patients' demands in a more complete way. Therefore, researchers seek to create methods and tools to facilitate the teaching of ophthalmoscopy for this audience, such as models of the human eye, (3) mannequins, (7) and online tutorial platforms. (8) Also, others suggest the use of more modern and less complex techniques such as panoptic ophthalmoscopes (9) and eye fundus photographs. (10) Although these new methods and tools are relevant for DO learning, there are gaps in the literature on the main factors contributing to DO not being properly trained during graduation, and not being common practice in medical care in general. The present study aims to analyze the self-perception of undergraduate medical students in the state of Mato Grosso about direct ophthalmoscopy, investigating their contact with the technique during graduation, and analyze the main factors responsible for the unsefaty in carrying out the exam and interpreting their findings . From these factors, methodologies can be developed favoring a stronger presence of examination within the context of the general practice.

methods
Literature was reviewed using Pubmed, Scielo, and Virtual Health Library (VHL) databases. The keywords used for the search were: "direct ophthalmoscopy", "ophthalmoscope", "learning" and "medical students". By reading the papers both in Portuguese and English, an overview on the teaching of DO in medical schools was drawn, and this information was used to create a questionnaire on the subject (Annex 1). 14) Would you be interested in attending a theoretical-practical training course in direct ophthalmoscopy?
The questionnaire was created and applied through the Google Forms platform between April 2, 2018 and August 4, 2018, and all questions were originally created by the author of the present paper, taking into account the main problems related to teaching and the application of DO according to the literature used, according to variables related to age, university, course period, having or not an ophthalmoscope, availability of ophthalmoscopes at the university, having taken classes involving DO during graduation, dedication to the study of ophthalmology during graduation, participation in activities beyond graduation that involved DO practice, considering DO an important exam, mastering the technique of the exam, knowing how to recognize the major alterations in the eye fundus, main factors that hinder the teaching, learning and practice of DO, being interested in participating in a theoretical-practical DO training course.
The target population comprised Medicine students from the six public and private universities in Mato Grosso State who were regularly attending the fifth or sixth year of the course during the period of application of the questionnaire. The universities were identified as Public A, B, C and D, and private A and B. In order to use the instrument, the snowball method was used: the author contacted the representatives of the classes involved in the research, who distributed o link for the Google Forms to the other students. There was no direct involvement of universities at any point in the research.
Data collection began only after the opinion of the Research Ethics Committee (CEP), under Opinion Number 2,575,630.
By accessing link, participants initially werepresented to the project title and a brief description of it, followed by the Informed Consent (IC). It was only after reading and declaring acceptance of the IC that the questionnaire was available. After answering the questions, all answers were automatically sent to the researcher to be inserted into the project database and subsequent statistical analysis.
After data collection was completed, a database was built on the software SPSS 20 for statistical analysis. Initially, an exploratory study was carried out, and subsequently the chi-square test was used to analyze proportions considering a confidence interval of 95% (CI: 95%).

Results
A total of 105 participants who were included in the target population answered the questionnaire. Regarding age groups, 65 (61.9%) were aged between 21 and 25 years; 27 (25 , 7%) between 26 and 30 years; 9 (8.6%) between 31 and 35 years; and 4 (3.8%) between 36 and 40 years. No candidate was under 20 years nor over 40 years old.
Among the university students interviewed, it was observed that more than 90% did not have their own ophthalmoscope. Regarding the availability of ophthalmoscopes in universities, the ratio of equipment in public universities was lower compared to that in private universities. However, there was no statistical significance (p = 0.117).
The ratio of students from public universities who had both theoretical and practical classes was 53.0%, statistically significant when compared to private universities, whose proportion was 12.8% (p <0.001). In private schools, it was observed that 66.7% of students had only theoretical or practical classes, and 20.5% had none. In public universities, 34.8% had only one class modality, and 12.1% had none.
Considering the type of university, the ratio of private school students who participated in extracurricular activities involving DO was higher among the Academic Leagues (12.8%). In public schools, the largest ratio of activities was in internships and individual training, both with 13.6% but without statistical significance (p = 0.050).
When the students were asked about believing that their respective universities guarantee the right conditions for learning DO, it was observed that the ratio of students who answered "yes" was 5.1% among private universities, and 34.8% among private universities, statistically significant (p = 0.001).
When asked about having sufficient theoretical and/or practical knowledge regarding DO, it was found that the ratio of students who reported knowing theory and practice was 9.1% in public universities, and 12.8% in private universities, statistically significant (p = 0.004). Considering the knowledge of only one between theoretical and practical modalities, the highest ratio of students for such approach was 80.3% and 51.3% respectively for students from public and private schools ( Table 2). The study found that the ratio of students with their own ophthalmoscope was 27.3% among those with theoretical and practical knowledge about DO, statistically significant when compared to students with theoretical or practical knowledge (1.4%) or no modality of knowledge (9.5%), with p = 0.002.
The ratio of students who claim their universities have ophthalmoscopes available for training was over 50% among groups with theoretical and practical knowledge, theoretical or practical, or no knowledge at all. This ratio was higher among those with theoretical and practical knowledge, with 81.8%, but without statistical significance (p = 0.182).
Considering the students who had theoretical and practical classes on DO until the fourth year of Medicine school and those who did not have any of these classes, it was observed that 100% of those who had both modalities have theoretical and practical knowledge on the exam according to their own perception, which was statistically significant (p = 0.001). Among the group with theoretical or practical knowledge 77.5% said they had theoretical and practical classes, and considering those who consider having no knowledge on DO, 22.2% had theoretical and practical classes. For this ratio analysis, 49 individuals who had only theoretical or practical classes were excluded.
The ratio of students who participated in extracurricular activities addressing DO was less than 50% in the groups with theoretical and practical knowledge, theoretical or practical knowledge, and with no knowledge, without statistical significance (p = 0.287). When considering whether the student believes that the university ensures proper learning of DO, 45.5% of those with theoretical and practical knowledge said "yes", which was also stated by 27.7% of those with theoretical or practical knowledge, and by 0.0% of those without any kind of knowledge, but without statistical significance (p = 0.007) ( Table 3).
Considering the factors listed affecting negatively the learning of DO, 76.2% of the students interviewed considered the lack of undergraduate training ( Table 4).
Among the five factors listed affecting negatively the performance of the exam during academic activities, 73.1% of respondents stated that lack of confidence is one of these factors, whereas the lack of importance of the exam was considered by 0.0 % (Table 5).

dIscussIon
The study found that contact with DO during Medicine graduation is insufficient for students to complete college with the knowledge and confidence required for the exam, and that this is mainly due to the limited opportunities for training in the classes during the course. The variables analyzed took into consideration subjective aspects involving students' self-perception regarding contact with DO and the skills developed on the examination during the first four years of medical school.
During the research it was evident that a good part of the students did not have theoretical nor practical classes during the first four years of graduation, especially in private schools. Only 23.8% of those involved in the research believe that they have had DO learning guaranteed by the university, and only 10.5% consider having knowledgeable on the exam in both theoretical and practical modalities.
It was possible to evaluate the impact that classes have on students, with statistical significance, by comparing students who had theoretical and practical classes on DO with those who had no classes. By randomly choosing one of these students who considered to have theoretical and practical knowledge on DO, it is certain that they took theoretical and practical classes. When selecting a student who considered not having any knowledge, the greater chance is that they did not have theoretical nor practical classes.
In fact, in listing the factors affecting negatively the learning of DO, poor training of the technique during graduation was the main aspect observed according to the self-perception of the target population. The high price of ophthalmoscopes was the factor least considered by respondents. Among the factors interfering negatively with the practice of the exam in the students' hospital activities, lack of confidence was predominant. The strong and important relation between training of a semiological technique and the consequent confidence to perform it is evident -and one is not possible without the other.
The study presented an original proposal based on the observation that there is almost no DO during medicine graduation, and that most students show little ability with DO. The main limitation found was the difficulty in collecting questionnaire   Table 3 Percentage distribution of the factors contributing to the theoretical and/or practical knowledge of Medicine internship students at universities in the State of Mato Grosso responses using the snowball method: there were several requests from the target audience students, but it took a long time to get an adequate number of participants. Perhaps this is especially due to the lack of interest in collaborating with the study and/or the large number of tasks to which medicine students are subject at this stage of the course -residency -having to deal with internships in health institutions, lectures, tests, and personal life.
Os estudos de Mackay et al. (5) e Schulz et al. (11) evidenced that the ophthalmoscope is a diagnostic equipment little used during medical school graduation. The same applies to medical courses in the State of Mato Grosso, considering the number of students who did not take at least one of the DO teaching class modalities, and also that more than 75% say that their schools do not guarantee the proper learning of DO technique. In addition, it is noteworthy that the lack of training opportunities during graduation was the most voted factor by respondents among those who negatively interfere with DO learning.  The question about DO knowledge in particular was aimed at assessing how confident students were in dealing with the technique. It was relevant that approximately one in 10 students considered themselves able to carry out DO which requires practical knowledge, and to interpret their findings which requires theoretical knowledge. These findings are consistent with the studies of Martins et al. (3) and Yusuf et al. (12) : these authors noted that the new generation of physicians has a growing number of people who lack the confidence and competence to deal with basic eye problems.
Schulz et al. (11) demonstrated that the main factors contributing to the proficiency of medical students in performing DO are more opportunities perform the exam with formal instruction at various semesters during the graduation course and even after course completion; clinical exposure to more cases with retinal abnormalities to refine the distinction between normal and altered eye fundus; receive more reviews and feedback about personal ability to exam. The results of these authors are consistent with the present study, considering that the lack of practices in the graduation course was found to have wide impact in the students' poor familiarity with DO.
The evaluation of the eye fundus with DO gives the physician an important tool to help diagnose diseases such as meningitis, endocarditis, retinitis, and child violence. (12) It is important to understand that the technique is a basic skill that should be part of the arsenal of all newly trained doctors. It is not something related only those skilled in the art, in the present case the ophthalmologists. (12) In their study, Yusuf et al. (12) made a quite pertinent comparison between DO and cardiac auscultation, two techniques that are part of the semiological arsenal that should be included in the training of the general practitioner. Both techniques require expensive equipment (stethoscope and ophthalmoscope), and are considered complex by medical students. However, medical schools would find it unthinkable to omit cardiac auscultation from the curriculum because of such justifications. Moreover, universities would certainly be opposed to those who considered cardiac auscultation a relevant examination only to the cardiologist. (12) Another tendency is to think that DO could be replaced by more modern techniques of examining the eye fundus (13) like panoptic ophthalmoscopes (1,9) and eye fundus photographs, known as retinography. (10) However, DO remains the most conventional and affordable method for eye fundus examination. (13) Key advantages of the ophthalmoscope include portability allowing it to be carried in a doctor's pocket and used in places where there is no more complex equipment, (5) and the price, (14) which is lower than other equipment for viewing the eye fundus. (5) A doctor who does not know how to do and/or interpret DO is a doctor with fewer diagnostic resources. This endangers the patient's health by generating very late or misdiagnosis, and is a factor to bring anxiety and financial expenses (12) that could have been avoided had the technique been known.
The most current national studies seek to evaluate different techniques for improving DO learning, as we can see in the studies of Damasceno et al., (1) Martins et al. (3) and Androwiki, (7) but there is lack of data on why medical students fail to learn and practice the technique. This study is novel regarding proposal to investigate the factors that are more related to the lack of practice to carry out DO, which may be used as support for the construction of new didactic approaches to academics. Analysis of direct ophthalmoscopy teaching in Medical graduation courses of Mato Grosso State conclusIon The analysis of the data obtained with the questionnaire showed that the DO has not been very relevant in the Medicine graduation courses in the state of Mato Grosso. This was evident as most students do not start graduation with the necessary skills to perform the exam, nor to interpret it. Lack of opportunities to learn the technique during graduation results in professionals with poor knowledge in a exam that is part of the basic medical semiology, and which can save the patient's sight or even their life in various health sectors and different medical specialties.
The idea is that at some point the medical community will realize the importance of DO and stop seeing it as a special exam or an exam that could be easily replaced by retinography. When this becomes a reality, DO may start to be more important in graduations courses, with due acknowledgement as it is with the cardiac auscultation and other indispensable semiological techniques.
Given the direction of the major obstacles to DO teaching in the State of Mato Grosso, one can begin to think of how to give students and their professors some better guidance on the true importance of the exam for public health. From this acknowledgement, measures can be taken to improve the teaching and learning of the technique, which in the long term will turn into direct benefits for the population of Mato Grosso, as well as other regions that will receive future doctors.